Three Part Question

In [patients with critical leg ischaemia] is the use of [sympathectomy] of any benefit in terms of [pain relief or limb survival]?

Clinical Scenario

You recently admitted an 82-year-old arteriopath who has had an 8-month history of critical leg ischaemia and who has debilitating pain at rest. Lower limb arteriogram confirms three-vessel disease not amenable to revascularisation. A below knee amputation was discussed with the patient. The patient asks you if anything could be done rather than an amputation. You have heard of sympathectomy, but wanted to confirm from the literature that this may be a viable option.

Sympathectomy group 45% at 1 month, 25% at 3 months. Control group 64% at 1 month, 45% at 3 months. No objective differences in any testing between groups

Comment(s)

Sympathectomy is proposed to act primarily via its vasodilator effects on the collateral circulation secondary to decreased sympathetic tone. This is deemed to improve tissue oxygenation and ulcer healing, and decrease tissue damage and pain. Pain is also deemed to be decreased by interrupting sympathetic–nociceptive coupling and by a direct neurolytic action on nociceptive fibres.
We identified 3 randomised controlled trials. Cross et al. in 1985 performed a trial of chemical lumbar sympathectomy on 37 patients with critical limb ischaemia. There was relief of rest pain in 66.7% of patients in the treatment group and in 23.5% of those in the control group at 6 months. However, there was no difference in ankle-brachial-pressure-index between the two groups.
Barnes et al. in 1977 performed a randomised trial in patients also receiving revascularisation. Although a reduction in peripheral vascular resistance was shown, no difference in ankle-brachial-pressure-index or graft survival was demonstrated.
Fyfe et al. in 1975 performed a randomised trial using phenol sympathectomy vs. local anaesthetic controls in patients with intermittent claudication but found no subjective or objective differences between the two groups at either 1 or 3 months.
The remaining studies were cohort studies. Van Driel et al. in 1988 performed a single centre retrospective study on 60 consecutive patients to evaluate the effect of surgical lumbar sympathectomy in the treatment of critical leg ischaemia. There were good results (defined as absence of rest pain, healing of ischaemic lesions and no major amputation) in 48% of limbs at six months. Limb survival at 6 months and 2 years were 65% and 59%, respectively. No operative deaths were reported.
Kim et al. in 1976 performed 61 lumbar sympathectomies on 58 patients with lower extremity arterial disease. Overall improvement rate (defined as disappearance of rest pain, healing of tissue and a generally non-painful useful limb for at least 6 months post op) was 60% while early amputation rate was 40%. The immediate postoperative death was 6.5% from cardiac causes.
Alexander et al. in 1994 performed 544 chemical lumbar sympathectomies on 489 patients with peripheral vascular disease. There was improvement in symptoms in 72% of the patients immediately and 35% at 8 months follow up. The amputation rate was 24% at 2 years.
Keane et al. in 1977 performed chemical lumbar sympathectomy on 132 patients with critical limb ischaemia. Good results (defined as relief of rest pain, feeling of warmth and life in the limb, avoidance of amputation) were seen in 52% of the patients at 16 months. Thirty-five patients required amputation despite sympathectomy.
Norman et al. in 1988 performed 174 surgical lumbar sympathectomies on 153 patients. Sixty-seven percent of the claudicant and 54% of the rest pain patients avoided further surgery after 5 years.
Perez-Burkhardt et al. in 1999 performed 100 surgical lumbar sympathectomies on 93 patients for invalidant claudication, ischaemic rest pain and trophic lesions. Good results (judged by absent rest pain, healed ischaemic ulcers no major amputation at 6 months) were seen in 58.5% of patients with claudication or rest pain and 61.7% of patients with trophic lesions. Amputation rate was 18.3% at 30 days post operatively.
Mashiah et al. in 1995 performed chemical lumbar sympathectomy on 373 patients with ischaemic lower limbs. Successful results (defined by termination of analgesic treatment, healed ulcers in 6–12 months and amputation not required) were achieved in 58.7% of the patients. Amputation rate was 20% and mortality 9%.
Matarazzo et al. in 2002 performed surgical lumbar sympathectomy on 385 patients with lower limb occlusive arterial disease. Favourable results were achieved in 63.6% of patients at 1 year.
Baker et al. in 1994 performed 132 surgical lumbar sympathectomy on 118 patients with severe peripheral vascular disease unsuitable for vascular reconstruction. Rest pain resolved in 86% within 6 months and 64% recovered from all trophic lesions over the same period. There was a 45% limb loss in the first 6 months. Peri-operative mortality rate was 4%.
Collins et al. in 1981 performed 45 surgical lumbar sympathectomies on 40 patients with rest pain or advanced skin changes. There was a good result (characterised by relief of rest pain and healing of ulcers for at least 6 months) in 44.4% of the patients. Amputation was performed in 42.2% of patients.

Clinical Bottom Line

Lumbar sympathectomy is a minimally invasive procedure with a low complication rate. Randomised controlled trials have failed to identify any objective benefits for lumbar sympathectomy, but subjective improvements in symptoms for patients with highly symptomatic critical leg ischaemia have been consistently demonstrated in multiple cohort studies with sustained symptom improvements in approximately 60% of patients. Lumbar sympathectomy should be considered for symptomatic patients with critical leg ischaemia as an alternative to amputation in patients with otherwise viable limbs.